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- Chetna K. Pande, MD, MPH*
- Amanda O’Halloran, MD*
- Rosalyn W. Stewart, MD, MS, MBA*
- Angela Nguyen, MD*
- Therese Canares, MD*
- *Department of Pediatrics, The Johns Hopkins Hospital, Baltimore, MD
AUTHOR DISCLOSURE
Drs Pande, O’Halloran, and Nguyen have disclosed no financial relationships relevant to this article. Dr Stewart has disclosed that she is the project director for a Health Resources and Services Administration grant to improve health-care delivery for people with sickle cell disease. Dr Canares has disclosed that she is a grant recipient for a research project involving offering dental screenings and preventive services through the joint collaboration of the Johns Hopkins–Walgreens Committee. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.
Presentation
A 14-year-old boy with attention-deficit/hyperactivity disorder, depression, autism spectrum disorder, and astrocytoma (status-post resection in infancy, no residual deficits) presents to the emergency department (ED) with 2 days of abnormal movements: facial twitching, jaw stiffness, and torticollis, progressing to whole-body tremors, agitation, diaphoresis, and altered mental status. Medications include fluoxetine 60 mg daily and lisdexamfetamine 60 mg daily, started 1 year ago. He recently gained independence with taking medications but took no medications in the past week. Two days ago his mother discovered his noncompliance and restarted his medications at the prescribed doses. Since symptom onset, he was seen in community EDs twice, received diphenhydramine for dystonia and lorazepam for agitation, and was discharged.
Vital signs are temperature, 98.8°F (37.1°C); blood pressure, 121 to 149/64 to 76 mm Hg; heart rate, 70 to 90 beats/min, with episodes of 170 beats/min when tremulous; respirations, 18 to 24 breaths/min; and oxygen saturation, 97% to 99% on room air. He is diaphoretic and agitated; his eyes are closed, but he opens them on command. He responds to questions verbally and follows commands. He has rotary and horizontal nystagmus, …
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